My experience with this has been in the setting of running supportive psychotherapy groups for patients recovering from psychosis.  I think that in the hospital setting, patients obtain most benefit from the experience of knowing other people suffer from the same things they do, and glean hope by seeing others improving.  After returning home, however, group supportive therapy is a natural antidote to the isolation that most people with psychoses face: you are not alone!.  Even those who have lost touch with family and friends can still make friends among others who understand them.  It is a joy to watch this develop as they come to care about and for each other.  Yalom wrote about this in his Group therapy textbooks.  I recommend them to you.

Hi William, thank you for your answer. Do you have any advice about how to manage groups and facilitate discussions? As it is a qualitative interview I would like to encourage the participants to discuss amongst themselves rather than direct answers, thoughts and ideas to me. Like you, I think that the most therapeutic part of groups like these is to have a space for people to discuss their experiences with psychosis with other people who will understand. Thank you for the book recommendation! 

I think it works best for me if I think of myself as being the "Group's" therapist as opposed to "all the patients'" therapist.  When I am asked a question I cannot reflect back to the whole group, I may answer generally, and add "but what do you all think?" , or "what does the group think?"  Yalom discusses behaving as though we are MEMBERS of the group, but I think that is tough for me with a group of psychotic patients.  Best of luck with your group.

There might be some ideas in the following books:

Family and Multi-Family Work with Psychosis: A Guide for Professionals (The International Society for Psychological and Social Approaches to Psychosis Book Series) 1st Edition by Gerd-Ragna Bloch Thorsen (Author), Trond Gronnestad (Author), Anne Lise Oxnevad (Author) Routledge; 1 edition (November 1, 2006)

Family and Multi-Family Work with Psychosis provides a practical step-by-step guide for professionals treating psychosis using family work.

The authors draw on over ten years of experience working with family and multi-family groups where there are members with a psychotic disturbance. They provide helpful guidance on vital issues, including setting up initial group meetings, crisis intervention plans, group structure, problem solving and communication in the group. Subjects covered include:

 the stress-vulnerability model

 the group structure and framework   family-work in early psychosis

 working with families of people suffering from psychosis and substance misuse

 what can the family do to be of help and support?

this accessible, jargon-free guide will be of great interest to anyone interested in investigating the potential for using family work to treat those with psychosis.

Drama, Psychotherapy and Psychosis: Dramatherapy and Psychodrama with People Who Hear Voices First Edition Edition

by John Casson (Author), Zerka Moreno (Foreword)

Routledge; First Edition edition (May 20, 2004)

John Casson - Winner of the British Psychodrama Association (BPA) Lifetime Achievement Award 2012!

Drama, Psychotherapy and Psychosis explores the use of drama and theatre in the challenging area of working with people who hear voices, focusing especially on survivors of abuse and those diagnosed as suffering from schizophrenia. In examining the often baffling and frightening world of psychosis the book offers alternative models of madness and the self, which form the basis for therapeutic interventions.

Illustrated by case histories and examples of practice, this book provides a description and analysis of voice hearing. Chapters cover areas including:

* historical perspectives on psychosis and hearing voices

* group psychodrama

* dramatherapy with individuals.

Drama, Psychotherapy and Psychosis demonstrates how creative action methods can be helpful to those who hear voices. It provides guidelines for good practice; essential to all those interested in promoting the safe use of these methods in therapy.

Hi Rosie, in the context of a focus group I would suggest you treat people with experience of psychosis the same as you would anyone else attending a focus group. Ensure there is a safe confidential non judgmental space for people to discuss their experiences. If you have been approved by an ethics committee you should have the psychosis specific safeguards in place. I'm a fan of this book. It has helped me when I have run focus groups in the past. Focus Groups: A Practical Guide for Applied Research By Richard A. Krueger, Mary Anne Casey. Best of luck with the research. What specifically are you exploring?

I second what Donal brings up - I would treat participants in the same way as any other participants with an experience of mental illness that might make them vulnerable.

Having worked with people who experienced psychotic episodes in a homelessness service, I found a couple of strategies useful before preparing to engage with a group:

- Brainstorming ways of redirecting conversations if they got too focussed intimately on the content of people's psychotic experiences/delusions. Not necessarily an issue if someone says "I tend to have delusions around religion, or feel like I am being persecuted", but more of an issue if people delve into the specifics by sharing things like "one of my recurring delusions is that I am Jesus and am on a cross and being burned and my family is being punished by needing to watch because I have been bad". One key reason for avoiding too much detail on delusions etc. is because some patients can be quite suggestible, and sub-consciously internalise details that have been shared and add them to their repertoire of delusions/thought patterns. I've seen this happen a few times, and it was really frustrating to realise it could have been prevented! Of course, if your goal is to understand the content of people's psychotic experiences, that's different - but then I'd suggest that it may be better to do that investigation in smaller, more private settings.

- Thinking of ways to de-escalate conflicts if people get agitated over delusions. For example, I've had to de-escalate a conflict between two service users because person A had delusions that involved them being a religious figure, and they found person B's delusions to be blasphemous. Things quickly escalated into a shouting match and would have turned physically aggressive without intervention. Worth bearing that in mind.

- I'm sure this is something you've looked at in detail, but pay attention to your questions and their phrasing! This involves structuring them in such a way that they are about common experiences, rather than about experiences that make people feel isolated. And be careful that the questions don't bias your participants towards specific answer patterns. For example, "does anyone feel comfortable sharing their families have responded to their psychotic episodes?" as opposed to "has anyone's family responded badly to their psychotic episodes?". The former gives opportunities for people to share positive experiences with their families, while the latter carries an assumption that people's families will always react badly.

- One thing I've found is that a lot of people with experiences of psychosis tend to have quite clear feelings on medication - whether favourable or not. This can quickly become a contentious subject, and one where certain voices try to push their opinions on others. 

- As far as general facilitation is concerned, definitely stressing that there are no right or wrong answers and that you're really interested in just hearing what people are willing to share makes such a difference in making people feel like they can participate freely. Bouncing questions back to the group and occasionally making sure that people who have been quiet have a chance to speak more also makes a big difference with this.

Hope it goes well! 

Thank you all so much for your very detailed and helpful responses. I particularly appreciate the sources you have suggested and the practical advice!

Donal, we're going to ask the participants about a new treatment for psychosis and we hope to later include them in the development of it.

I think that Alienor's point about how people with experiences of psychosis tend to have strong opinions about medication is interesting. I'm sure the participants will have strong opinions and ideas about this new treatment - very interested to see what they say!

It depends on how the focus group members are selected. If they volunteer for it, they will likely be forthcoming with their opinions and it will be a focus group like any other. Maybe keep it short or allow breaks or allow people to leave and return if they need to.

But if you have chosen a random representative group with a diagnosis of psychosis, there may be difficulties of response for many, so that a few members make 'take over' the group. You may need to 'go round the group' to allow everyone to have a say if possible. The members will tend to look only at the group leader and speak only to the group leader and to not remember each other's names - so you may need to introduce some warm up games. It may be an idea to have two group leaders instead of one - a male/female duo of group leaders often works well.

Mary's comment on keeping it short and allowing breaks or for people to leave and return is excellent. Talking about psychosis can be very emotionally fraught for some people, but still be something they want to do. I'd suggest having some tea/coffee and biscuits available as well so that people feel like they can get up and go fix themselves a cup of tea or get a biscuit if they're getting overwhelmed and need to disengage for a bit. Having a clear "just feel free to go to the bathroom whenever" rule is good too because it means someone can excuse themselves for a bit if they're uncomfortable.

In groups I've facilitated, I've also always had soft toys, some squishy toys, and putty available in case anyone wanted something to fidget with while the session was going on. I also let people colour/doodle if they want to so that they can do that if they're feeling overwhelmed.

Hi Rosie. Very interesting. If you are looking at involving service users in the development and design of the intervention, you might consider linking in with REFOCUS.

http://www.ncbi.nlm.nih.gov/pubmed/26450586 

http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366%2815%2900086-3/abstract